New Patient Form – Tri County Hematology & Oncology Associates

New Patient Intake

Patient Registration Form

Please fill out all required fields. This information helps our team prepare for your first visit and ensures we can provide you with the best possible care.

Personal Information

First Name *

Last Name *

Date of Birth *

Sex *

Phone Number *

Email Address

Home Address *

Medical Information

Referring Physician

Primary Diagnosis / Reason for Visit *

Current Medications

Known Allergies

Insurance Information

Insurance Provider *

Member ID *

Group Number

Preferred Location *

I consent to the collection and use of my personal and medical information for the purpose of receiving care at Tri County Hematology & Oncology Associates. *

What to Bring

›Photo ID (driver's license or passport)
›Insurance card(s)
›List of current medications
›Referral letter (if applicable)
›Prior medical records and test results
›Pathology reports (if available)

Questions?

Our team is happy to assist you with the registration process or answer any questions before your first visit.

Massillon: 330-478-0001 Dover: 330-556-6464